— 生理適應 · EASY · MCQ —
一位病患因深層靜脈栓塞 (DVT) 入院。下列哪項護理措施是禁忌的？
A client is admitted with deep vein thrombosis (DVT). Which nursing action is contraindicated?
- AApplying warm compresses施予熱敷
- BAdministering anticoagulants as ordered依指示給予抗凝血劑
- CElevating the affected limb抬高患肢
- DMassaging the affected calf✓ 正解按摩患側小腿
— Explanation · 中文詳解 —
深層靜脈栓塞（DVT）病人患肢嚴禁按摩，主要因為機械性的按摩壓力極易導致血管壁上的血栓脫落，形成栓子隨血流進入肺循環，引發致命的肺栓塞（Pulmonary Embolism）。護理重點在於預防血栓脫落，應採取患肢抬高以協助靜脈回流，並配合抗凝血劑治療。護理師應指導病人避免穿著過緊的衣物或長時間維持不良姿勢，以促進血液循環。
Massaging the affected limb is strictly contraindicated in clients with deep vein thrombosis because mechanical pressure can dislodge the thrombus. Dislodgement may cause the clot to travel to the lungs, resulting in a potentially fatal pulmonary embolism; instead, nurses should elevate the limb and administer anticoagulants as prescribed.